Guideline Nixes Aspirin for DVT Prevention in Travelers

Action Points

Explain that in an updated guideline, doctors are urged to consider a patient's risk for deep vein thrombosis (DVT) and venous thromboembolism (VTE), as well as their risk for bleeding before prescribing prophylaxis.

Point out that for hospitalized patients who are at risk of thrombosis, the guidelines recommend using low-dose molecular-weight or unfractionated heparin or fondaparinux for prophylaxis.

Clinicians should not recommend that all travelers use aspirin for prevention of deep vein thrombosis during long plane trips, according to a new recommendation.

In an updated guideline, doctors are urged to consider the individual patient's risk for deep vein thrombosis (DVT) and venous thromboembolism (VTE), as well as their risk for bleeding before prescribing prophylaxis, Gordon Guyatt, MD, of McMaster University in Hamilton, Ontario in Canada, and colleagues reported in CHEST.

"There has been a significant push in healthcare to administer DVT prevention for every patient, regardless of risk," Guyatt said in a statement. "As a result, many patients are receiving unnecessary therapies that provide little benefit and could have adverse effects."

Airline passengers on long-distance flights are generally unlikely to have thrombosis while on board, but some patients are at risk. Most individuals with travel-associated VTE have one or more known risk factors for thrombosis, which include a history of VTE, recent surgery or trauma, pregnancy, obesity, thrombophilic disorder as well as estrogen use, advanced age, and limited mobility.

The guidelines recommend that passengers frequently move about the plane as well as stretch calf muscles while seated. Additionally, the guidelines suggest use of below-knee compression stockings that provide 15 to 30 mm Hg of pressure at the ankle.

The researchers noted that sitting in an aisle seat, which facilitates ease of movement, is helpful.

For hospitalized patients who are at risk of thrombosis, Guyatt and colleagues recommend using low-dose molecular-weight or unfractionated heparin or fondaparinux for prophylaxis. The choice of the specific agent should be based on patient preference, compliance, and ease of administration, they added.

Hospitalized patients who aren't at risk of thrombosis, on the other hand, should not receive any pharmacologic or mechanical prophylaxis, they wrote. In addition, patients at a high risk of bleeding should not receive anticoagulant prophylaxis.

However, if a patient is at high risk of thrombosis and also at high risk of bleeding, compression stockings or intermittent pneumatic compression may be used.

With regard to orthopedic surgery, aspirin can be used to prevent thrombosis in patients undergoing total hip and total knee arthroplasty, the researchers said. Previously, it was not to be used as a single agent for prophylaxis is any surgical population, they noted.

However, the guideline states that one panel member strongly believed aspirin should not be included as an option.

The guideline also reflects the recent approvals of new anticoagulant classes including direct thrombin and factor Xa inhibitors. In addition to low-dose unfractionalted heparin, low-molecular-weight heparin, and fondaparinux, the researchers recommend use of apixaban (Eliquis), dabigatran (Pradaxa), and rivaroxaban (Xarelto) to prevent thrombosis in hip and knee replacement patients.

Yet they noted that low-molecular-weight heparin should be given preference over the other agents, because the latter may carry higher risks of bleeding, have lower efficacy, and have less long-term safety data.

The updated guideline also recommends the use of dabigatran (150 mg twice daily) as antithrombotic therapy for atrial fibrillation patients at high or intermediate risk of stroke, in place of adjusted-dose vitamin K agonist therapy. But patients at low risk of stroke shouldn't be put on anticoagulants, they wrote.

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